The Effectiveness of Gamification Diabetes Education Program for Poorly Controlled Type 2 Diabetic Patients: A Randomised Controlled Trial.

The prevalence of Diabetes Mellitus (DM) is increasing internationally, corresponding with the rising aging population. Nearly half of the population was unaware that they have diabetes and the number is portended to reach 439 million worldwide by the year 2030. This global phenomenon draws the attention on the enormous health care expenditure spent on managing DM alone. The financial burden of diagnosed diabetes was 2.3 times higher than the absence of it, reflecting as one of the barriers in engaging diabetes patients and promoting self-efficacy. Type 2 diabetes patients, also known as non-insulin dependent diabetes, are the high-risk population to experience a diabetes-related complication, such as, end-stage renal failure (ESRF), stroke, cardiovascular disease and amputation of the limbs, all of which can lead to poor quality of life (QoL), depression and even death.

Local statistics demonstrated an increase of 25.6% (2013 to 2015) of diabetic patients in an outpatient endocrinology clinic and ten percent hospital readmission rate of patients due to poor compliance and diabetes-related health issues. A retrospective study done locally in the primary health care polyclinics had shown an incline percentage of attendances with DM, from 8.8% to 9.8% over the past five years (2011 to 2015), reflecting an increase of 8155 diabetic patients. Their average age group is 40 years old. According to American Diabetes Association (ADA, 2014), glycosylated hemoglobin A1c (HbA1c) value has been recognized as the standard measurement in diagnosing and treating DM and, the value of ≤7% was correlated with a reduction in diabetes complications. Each 1% of the reduction in HbA1c values over ten years is equivalent to 21% of the reduced risk of diabetes-related outcomes and death, including 14% of the reduced risk for myocardial infarcts and 37% for microvascular complication (p<0.0001). Effective diabetes management or self-efficacy appears strongly related to healthy lifestyle modification and behavioral change, such as medication adherence, compliance to treatment-regime and exercising.

In comparison, poor access to quality care, stress, and obesity has a detrimental effect on HbA1c values and increased the risk for diabetes-related complication as mentioned. Poor clinical outcomes consists of HbA1c >7.0%, systolic blood pressure > 130mmHg, body mass index (BMI) of ≥ 25, abnormal low-density lipoprotein (LDL) and high-density lipoprotein (HDL) measurement. Poor diabetes outcomes are related to depressive symptoms, anxiety, low self-efficacy, poor self-esteem, eating disorders and diabetes-related stress, including osteoporosis among the Chinese diabetes patients. Hence, diabetes patient education is an important cornerstone in self-management, self-efficacy, and long-term behavior change.

Patient education is defined as a process of providing skills and knowledge, including giving advice and alternatives for lifestyle modification in diabetes management and glycemic control. Health education aimed at preventing diabetes-related complications and can lead to improved health literacy that supports greater empowerment in health decision-making and outcomes. There is no consistency of teaching contents in diabetes educational program. It could be due to that the program was led by a different healthcare professional, such as pharmacist, dietician or nutritionist, diabetes nurse educator and or psychologist.

To some extent, the benefits of these diabetes education programs had shown improvement in self-management and glycemic control, including a reduction in depression, and enhancing self-efficacy behaviors and better quality of life. However, all these require an ongoing positive reinforcement in order to achieve a successful long-term intervention and good glycemic control. An effective diabetic patient education would mean success in diabetic self-management, which is associated with better metabolic control, lower costs of therapy through complication prevention, lower mortality rate, reduced readmission rates, improve QoL and, better self-efficacy and health behaviors.